Healthy Lifestyles Solutions
Fitness Program
SM
With Independence Blue Cross’
Fitness Program you can get
up to $150 back
You don’t have to enroll in the Healthy Lifestyles Solutions Fitness
Program to become eligible for reimbursement. When you
meet the eligibility requirements, just submit your documentation to
ibx.com/reimbursements to request reimbursement.
Four easy steps
1. Join an approved fitness center.
Choose a full-service fitness center that includes amenities for continuous
cardiovascular, flexibility, and resistance training. You’ll find more
information about choosing an approved fitness center on page 2.
2. Exercise at your chosen fitness center regularly.
You need to work out at your approved fitness center 120 times during a
365-day period (example: June 2014 through May 2015). Your workouts
must include continuous cardiovascular, flexibility, and resistance training
and last approximately 30 minutes.
3. Record your workouts.
Record each workout using one of the methods listed on page 4. You
may record only one workout per day with a minimum of eight hours
between logged workouts. After you complete 120 workouts, you can
request a reimbursement.
4. Submit your documentation and request your reimbursement.
Log on to ibx.com/reimbursements and upload copies of the
following documentation:
•proof of payment (receipts must be submitted on fitness facility
letterhead, or a copy of the membership contract must accompany
the receipt);
•record of your workouts (completed logbook found at the end of this
document or a computer printout of your workouts from your gym).
Once all of your documentation is submitted, you can request your
reimbursement be paid by direct deposit or American Express rewards card.*
* Please note that American Express charges a fee of $4.00 plus three percent of
reimbursement amount.
1
Fitness Program guidelines
Eligible members
In order to be eligible for reimbursement, participants must be age
18 or older.
Selecting an approved fitness center
The Fitness Program rewards you for incorporating a well-rounded exercise
program into your routine. To be eligible for the fitness center reimbursement,
you must choose a full-service fitness center that offers a variety of
cardiovascular, flexibility, and resistance training in a supervised setting.
Eligible fitness centers
Eligible full-service fitness centers generally feature most of the
following amenities:
•group exercise classes (e.g. aerobics, spinning, body sculpting, kickboxing)
•resistance training equipment (e.g., weight machines)
•free weights
•cardiovascular training equipment (e.g., treadmills, stationary bicycles,
elliptical trainers)
•pool for swimming laps
•track for running/walking
Ineligible fitness centers
Membership at athletic clubs that focus primarily on a single competitive or
recreational sports activity are not eligible for reimbursement, even if the
activity includes elements of a comprehensive exercise program. While we
recognize that activities such as martial arts, rowing, tennis and basketball
are excellent ways to stay fit, they often do not require consistent, year-round
attendance or proper supervision. Nor do these activities incorporate all the
elements of a comprehensive exercise program. Therefore, participation in
these programs does not qualify for reimbursement. Examples of ineligible
programs and facilities include:
•tennis/squash/racquetball
•basketball
•golf
•Pilates/yoga class
•martial arts/karate class
•sports leagues
•recreational swim clubs
•dance instruction
•outdoor “boot camp” style program
•sculling/style program rowing
•chiropractic services
2
Lifetime fitness center memberships
If you purchase a lifetime membership at a fitness center, you are eligible to
receive a reimbursement of up to $150 of the membership fees paid once per
calendar year as long as the required number of workouts are completed.
Family fitness center memberships
Family memberships are eligible for the reimbursement under the
following conditions:
•Each family member who requests the reimbursement must be listed on
the membership contract.
•Each family member who requests the reimbursement must individually
participate in the Fitness Program and fulfill all Fitness Program
reimbursement requirements.
Each eligible family member may receive reimbursement of up to $150 of his
or her portion of the total annual membership fees once per calendar year.
Example:
•Family fitness center annual contract fee is $700.
•Four family members are listed on the family fitness facility contract.
•Two family members are 18 or older and, therefore, are eligible
for reimbursement.
•$700 ÷ 2 = $350 (each eligible family member’s portion of the total
contract fee).
In this example, if the two eligible family members complete
all Fitness Program requirements, each will receive up to $150
(his or her portion of the family fitness facility annual contract
fee). If only one eligible member completes all Fitness Program
requirements, the family member will receive up to $150 (his or
her portion of the family fitness facility annual contract fee).
3
Reimbursement rules
and requirements
•You must complete 120 workouts during a 365-day Fitness
Program period. However, the 365-day time period does not
need to be within the same calendar year as the reimbursement.
For example, you could get a reimbursement paid out in
January 2015 for 120 workouts documented in 2014.
•You must have coverage with Independence Blue Cross at the time
of your request for reimbursement.
•You are only eligible for one reimbursement per program, per
calendar year.
•Dependents must be at least 18 years old to be eligible for reimbursement.
•Logging in for another member at a fitness center is prohibited.
•Falsification of information in order to receive your reimbursement is
strictly prohibited.
How to record your workouts
Choose a primary method of recording your workouts that works best for you:
•logbook on page 6
•computer printout from your fitness center that shows all workout dates
Record workouts using the logbook
To record workouts using the logbook on page 6, ask a fitness center
representative to sign and date the logbook each time you work out.
You may also use the logbook to record your workouts when you visit a fitness
center other than your primary fitness center (e.g., when you work out while
traveling or vacationing out of town).
Record workouts using a fitness center’s
computer printouts
You may choose to use your fitness center’s computer printout as your primary
method of logging workouts. However, keep in mind that Independence Blue
Cross cannot assume any responsibility for the reliability of fitness center
computer systems. For this reason, if you select a fitness center computer
printout as your primary method of logging workouts, you also accept the risk
that all your workouts may not be credited toward your reimbursement should
your fitness center have technical issues.
4
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Other important information
•Independence Blue Cross does not guarantee the solvency of any fitness
center and, therefore, has no liability should a fitness center close.
•For members other than those enrolled in a Medicare Advantage plan,
Healthy Lifestyles Solutions programs are value-added. They are not part
of the health care benefits you have purchased and, therefore, are subject
to change without notice.
•At Independence Blue Cross, we encourage all of our members to adopt
and maintain a regular fitness program. However, if you are 40 or older,
overweight, have a history of high blood pressure or heart disease, or
have any other health concerns related to exercise, you are encouraged to
consult your doctor before beginning any exercise program.
•If you are unable to complete workouts due to a medical procedure,
please call 1-800-590-8880.
5
Questions?
Call Healthy Lifestyles
Solutions at 1-800-590-8880.
Healthy Lifestyles Solutions
Fitness Logbook
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Member name
ID #
Instructor/fitness facility representative must acknowledge each w
­ orkout with date and signature.
Credit will only be issued for workouts completed during supervised hours.
Date
Fitness facility
representative signature
Workout
time
Date
Fitness facility
representative signature
Workout
time
1.
❑ am
❑ pm
31.
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❑ pm
2.
❑ am
❑ pm
32.
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3.
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33.
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4.
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34.
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5.
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35.
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6.
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36.
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6
Date
Fitness facility
representative signature
Workout
time
Date
Fitness facility
representative signature
Workout
time
61.
❑ am
❑ pm
91.
❑ am
❑ pm
62.
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❑ pm
92.
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63.
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93.
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96.
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67.
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97.
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68.
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98.
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69.
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Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East
and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
17863 2014-1987 (10/14) FITNESS